Over the past 15 years, there has been a dramatic increase in the abuse of purified cocaine preparations throughout the industrialized world. The potential lethality of the drug is now recognized, and a growing series of case reports indicate that cardiotoxicity may be an important factor in the morbidity and mortality associated with the drug. Acute myocardial infarction is a demonstrated risk both in subjects with and without pre-existent coronary artery disease. The arrhythmogenic potential of cocaine is less clear and appears to have been overemphasized, although several documented cases of ventricular arrhythmia following cocaine use have been reported. Cardiomyopathy and myocarditis associated with cocaine have also been described, but an etiologic relationship is presently inferential. Based upon presumed pathophysiologic mechanisms, beta adrenergic blocking agents are recommended for arrhythmias, and calcium channel blocking agents and/or nitrates for ischemic syndromes related to cocaine. It is emphasized that these recommendations are based upon a paucity of relevant clinical studies, and controlled clinical trials to establish their efficacy have not been performed.